REFUGEE HEALTH SCREENER - 15 (RHS-15)

1 REFUGEE HEALTH SCREENER - 15 (RHS-15) DISCLAIMER The English Version of the RHS-15 is for informational purposes only. It is not intended for use in REFUGEE populations. Bilingual versions of the RHS-15 have been translated by professional translations and with the participation of the community so that each question is asked correctly according to language and culture. Using the English version negates the sensitivity of this instrument. If you would like to receive bilingual versions of the RHS-15, please contact Pathways to Wellness at Pathways to Wellness.

2 Integrating REFUGEE HEALTH and Well-Being Page 1 UTILIZATION REQUEST AND AGREEMENT Pathways to Wellness Integrating REFUGEE HEALTH and Well-Being Creating pathways for REFUGEE survivors to heal REFUGEE HEALTH SCREENER - 15 (RHS-15) Pathways to Wellness is a project of Lutheran Community Services Northwest, Asian Counseling and Referral Services, Public HEALTH Seattle & King County, and Michael Hollifield, Generously funded by the Robert Wood Johnson Foundation, The Bill and Melinda Gates Foundation, United Way of King County, The Medina Foundation, Seattle Foundation, and the Boeing Employees Community Fund Pathways to Wellness.

3 Integrating REFUGEE HEALTH and Well-Being Page 2 UTILIZATION REQUEST AND AGREEMENT Date of Request: Name: Institution: Department (if applicable): Your Position: Address 1: Address 2: City: State: Zip: Country: Email: Phone Number: INSTRUCTIONS Please complete the fields below Where did you hear about the RHS-15? In a journal publication List: From a colleague Other (please specify): What is your intended use of the RHS-15?

4 Clinical assessment Research Other (please specify): If you plan to use the RHS-15 for research, please briefly describe your research or use: Ethnic and/or language group(s): Arabic Russian Nepali Spanish Karen Somali Burmese Age range 14-21 21-64 65-older Context: (check all that apply) refugees Asylum seekers Validity for screening Comparison to another instrument How many refugees do you screen a year? 25-50 50-100 100-200 200 or more What is the setting for administering the RHS-15?

5 HEALTH setting Primary care Public HEALTH Resettlement agency CBO Other (please specify) Funding source? Federal grant Foundation Intramural grant None Is there other pertinent information about how your organization will utilize the RHS-15? Pathways to Wellness: Integrating REFUGEE HEALTH and Well-Being Page 3 UTILIZATION REQUEST AND AGREEMENT Statement of Agreement I understand that the purpose of this agreement is to improve the use and dissemination of the REFUGEE HEALTH SCREENER 15 (RHS-15).

6 Any and all shared information and data between myself, or my institution, and Pathways to Wellness partners is to be utilized to improve the RHS-15. I also understand that I, and/or my institution, may negotiate with Pathways to Wellness partners how shared information and data will be used for institutional and/or scientific reports. I agree to utilize the REFUGEE HEALTH SCREENER 15 (RHS-15) in its current form and for its intended use unless otherwise specified in subsequent agreements. (Please check the box that reflects your desired use of the RHS-15) I and/or my institution will use the RHS-15 for clinical purposes only.

7 We do not have the capacity to engage in research, but agree to a qualitative interview to discuss challenges and successes with the RHS-15 so the tool can be further developed. I and/or my institution will use the RHS-15 for clinical purposes only. I/we agree to share with Pathways to Wellness partners the following information within a reasonable amount of time of a written request: 1. The number of screenings conducted. 2. Time of screening administration during resettlement ( , six weeks after date of arrival in the , one year after date of arrival in the , etc.)

8 3. Age, gender, and ethnic/language group, and screening score of participants screened. I and/or my institution are interested in partnering with Pathways to Wellness partners on further evaluative projects about the RHS-15 and/or subsequent versions of the RHS-15. I/we understand that I/we will negotiate with Pathways how to proceed in such projects regarding lead, institutional review board approvals, data collection and management, and authoring of scientific reports. I/we agree to share with Pathways to Wellness partners the following information within a reasonable amount of time of a written request: 1.

9 The number of screenings conducted. 2. Time of screening administration during resettlement ( , six weeks after date of arrival in the , one year after date of arrival in the , etc.) 3. Age, gender, and ethnic/language group, and screening score of participants screened. 4. Clinical information regarding 1) the number of those screened referred to care, 2) the number of positive screened persons that went to care, and 3) treatment outcomes. 5. A summary of any other qualitative or quantitative evaluations about the utility of the RHS-15 (negotiable on execution of the agreement).

10 Pathways to Wellness: Integrating REFUGEE HEALTH and Well-Being Page 4 UTILIZATION REQUEST AND AGREEMENT Requestors signature: _____Date: _____ Requestor s printed name: _____ Thank you for your interest in utilizing the REFUGEE HEALTH SCREENER -15 (RHS-15). We are interested in your findings, recommendations for further use and development, and collaboration on research and development. Please return the form to: Pathways to Wellness Beth Farmer, MSW International Counseling & Community Services 4040 S 188th St., #200 Seattle, WA 98188 206-816-3252 You may fax to: 206-838-2680 2011 Pathways to Wellness Pathways to Wellness is a program of Lutheran Community Services Northwest, Asian Counseling and Referral Service, Public HEALTH Seattle & King County, and Michael Hollifield, Generously supported by the Robert Wood Johnson Foundation, the Bill & Melinda Gates Foundation, United Way of King County, the Seattle Foundation, the Medina Family Foundation, and the Boeing Employees Community Fund.